Monday, May 31, 2010
Fasting Glucose: 82.
Blood pressure, resting pulse: 109/76, 66.
Exercise: 4 mile run.
Considering that yesterday was a non-exercise day for me (and a long night out -- I was in San Francisco playing Irish music, and the session ran until 2 o'clock this morning), my low fasting result of 82 is slightly surprising. But I had a light, early dinner with no snacking afterwards, so I guess that helped.
The likely explanation for my systolic blood pressure being unusually low today -- and my resting pulse unusually high -- is that I did the measurement about 40 minutes after completing a hilly run. During exercise, both my systolic pressure and my heart rate are elevated, and both of them begin falling almost as soon as the workout is over. The pressure falls fast, and in fact dips below my usual range for a while. The heart rate, on the other hand, falls rapidly at first, and then (once it gets under 100) declines more slowly, and takes a long time to settle on my usual resting rate. I don't know anything about how to interpret these patterns, apart from the fact I've reported them to my doctor and nothing seemed amiss to him. He did say that if my blood pressure and heart rate stayed high after a workout was over, that would be a bad sign.
He didn't say exactly why that would be a bad sign, but I think I get the picture: it could indicate that an important tissue (such as heart muscle) was not being adequately served by the arteries that fed it, and was therefore "falling behind" on fuel and oxygen during the stress of exercise. The fact that my pressure and pulse begin falling as soon as I stop exercising presumably indicates that my cardiovascular system is not falling behind in that way.
[Postscript: four hours later, my blood pressure was up to 115/77 and my pulse was down to 52. No surprise there.]
Here's something I learned during my run today: if you're running an out-and-back course, and you run past a dead skunk as you're going downhill... then that skunk is going to smell even worse when you pass it again on the way back, because then you'll be going uphill, and you'll be breathing a lot harder. Make a note of that.
Taking in deep lungfuls of air that smells bad is enough to make you believe in old-fashioned ideas about disease being caused by "bad air". In fact, "bad air" was the name that the Italians once gave to a dangerous disease that was also known as "Roman fever". In Henry James's famous story Daisy Miller, the naive heroine wants to see the Colosseum in the moonlight, and she ignores everyone who advises her sternly that exposing oneself to the night air of Rome is how you catch the disease. And of course it turns out that their warnings were well-founded: immediately after her exposure to the "bad air", she falls ill and dies of the disease. The Italian phrase for "bad air", by the way, is "mal aria".
James was writing in 1878 -- in other words, two decades before it was shown that malaria is transmitted by mosquitoes. It was, indeed, something in the night air that was infecting people with the disease, but it wasn't a bad smell or some other invisible influence -- it was biting insects which carried a parasitic microorganism called Plasmodium. Although you could get a mosquito bite under various circumstances, the risk was highest if you went out after dark, especially if there was a swamp or other standing water nearby. The bad odor of a swamp certainly indicated that your risk of a mosquito bite was elevated, but it wasn't the odor itself that was putting you in danger.
With the wisdom of hindsight, it's easy to think the Italians of the 19th century were being awfully naive to assume that the night air, or a bad smell in the air, could have such a powerful influence all by itself that it could make you fatally ill. But we're really not any more clear-sighted about these things today. We notice a statistical association of Thing A with Thing B, and we leap to two conclusions: (1) that Thing A is the direction and simple cause of Thing B, and (2) that getting rid of Thing A will also get rid of Thing B. These conclusions could easily be wrong.
For example, the association of high LDL cholesterol levels in the blood with high rates of heart disease is a fact of interest, but until we know exactly why those two things are associated with one another, any practical use we try to make of the information is likely to be misguided. Doing something that brings down your LDL cholesterol level might prevent heart disease, and might not. A lot might depend on how you bring the level down. (The "effectiveness" of cholesterol-lowering drugs is usually measured only in terms of whether they lower your cholesterol, not whether they actually reduce your risk of dying from a heart attack -- which is a good thing for the makers of the drugs, because the the drugs look a lot better if you don't ask how much difference they make to patient survival.)
And the idea of reducing your cholesterol level by eating less cholesterol seems a bit naive, too, given that most of the cholesterol in the blood is created within the human body, not ingested. Strict vegetarians consume no cholesterol (it's not present in plant foods), but they nevertheless have cholesterol in their blood. It's certainly worth finding out why some people produce too much cholesterol, but the idea that anything which makes them produce less of it will also solve their cardiovascular problems needs to be demonstrated, not assumed.
Yes, I understand that cholesterol deposits on the walls of blood vessels tend to lead to arterial blockages, and therefore to heart attacks. But do we know for a fact that the rate at which cholesterol deposits build up is related only to the amount of cholesterol in the blood? There are probably other factors involved here, and it could turn out that one of those other factors is actually more important.
I'm only using cholesterol as an example here;
I think there are a lot of issues related to health in general, and diabetes
management in particular, which we are probably oversimplifying -- and perhaps
dangerously so. Will the next century look back in wonderment at the naive
interpretations we're putting on the medical evidence in front of us? Will we
look as dopey to them as those who once thought that there was a lot of
malaria near swamps because the air smelled bad there?
Saturday, May 29, 2010
Fasting Glucose: 85.
Blood pressure, resting pulse: 115/72, 54.
Exercise: 7.5 mile trail-run.
Ah -- we've finally got what I would consider normal weather for Northern California in May: sunny, clear, 82 degrees. Naturally I took advantage of the opportunity to go to the state park to do a trail run.
After so much rainy weather this spring, I expected the trails to be a lot more crowded today than they were. I did see some people -- mountain bikers, hikers, equestrians, a few runners -- but not as many as I was expecting.
But this is a holiday weekend, so maybe a lot of the more outdoorsy people living around here had gone out of town, and were getting their exercise in some more distant place.
Earlier in the day I took care of an errand I've been putting off -- getting some new running shoes. It definitely had to be done, as you can see by comparing the amount of tread on my old shoes to the amount of tread on the shoes (of the same model) that I bought today.
Buying running shoes is a big, frustrating issue for people who run a lot. Finding shoes that are right for you (especially in terms of not causing you any running injuries) is a complicated business. I buy mine from a store that caters to serious runners. When you try on a pair of shoes there, they make a video of you running in them on a treadmill, so that they (and you) can see how the shoes affect the way your feet contact the running surface. This matters, believe me -- if your feet come down wrong when you run, it can cause "shin splints" (a type of injury that has been known to make strong men cry). I have had shin splints from running in the past, which is what led me to start buying my running shoes from specialty stores (and taking certain other precautions to avoid running injuries).
The pair of shoes I bought today cost $109.25. I could have bought something far cheaper at a chain store that would have looked like just as serious a pair of running shoes, but that's not something I would even consider any more. I've tried that approach, and the money-savings was not remotely worth the pain.
And speaking of pain, I'm afraid I took a fall once again while running today. Actually, it wasn't a very bad fall, and I didn't hurt myself. No scrapes. No bruising that I can see. My shirt is a definite casualty, though. The iron-oxide-rich soil of park property seems to have left a permanent mark. Here's what the shirt looks like now -- after washing it.
I think I'm either going to have to get rid of it or dye it brown.
The fall occurred becase, after running in dazzling sunshine for several minutes, I ran through a very dense little gathering of trees -- and in the heavy shade there I failed to see a tree root sticking up out of the trail, and tripped on it. It probably wouldn't have happened if I hadn't been wearing sunglasses. However, my eyes are pretty sensitive to bright light, and I don't think I can run without eye-protection on a sunny day. I guess what I need to do is find some sunglasses that block UV but aren't so dark that I can't see where I'm going when I move suddenly into the shade. Those super-ugly yellow lenses might do the trick, but I'm hoping I can find an alternative. I've never been a fan of looking at the world through urine-colored glasses.
It's long been known that diabetes patients have a high rate of depression, but it's never been very clear whether this is so merely because it's depressing to have a chronic disease, or if there is a more direct physiologic connection between the two problems.
Now it's claimed, at least in this article on Medscape, that depression is an inflammatory disease. It seems that depressed people have elevated levels of TNF-alpha and IL-6, two "cytokines" (signaling molecules which, for obscure reasons, are not considered hormones even though they serve the same function). Both of these cytokines are related to the inflammatory response. Now it turns out that they are related to depression, too.
So, people with diabetes have one more reason to reduce inflammation. The old reasons (inflammation causes insulin resistance and heart disease) are still in effect, but you also need to be aware that the inflammatory response also seems to promote depression.
The thing is, how do you reduce inflammation? Well, there are plenty of things that trigger an inflammatory response: stress, high blood pressure, excess body fat. Maybe excess blood sugar, too. Addressing those problems would seemingly help with depression. Generally speaking, all of the things you want to be doing anyway, in order to get the best possible control of your diabetes, will also be useful in terms of reducing inflammation, and thus reducing the risk of depression.
Of course, once people get depressed, it becomes hard for them to see the point of doing anything at all to get their health under better control. So, once inflammation makes people depresed, they become less capable of doing anything about reducing their inflammation problem.
The depression/inflammation linkage is yet another one of those self-reinforcing problems that seem to occur all the time in connection with diabetes. Man, this disease is just one vicious circle after another! Every harmful effect that diabetes can have on you also has some additional effect that makes it hard for you to do anything about the main effect it's having on you.
I guess that's why it's important to act forcefully and immediately in getting your diabetes under control. The longer you wait to respond, the harder it is to respond effectively.
Friday, May 28, 2010
Fasting Glucose: 82.
Blood pressure, resting pulse: 121/72, 53.
Exercise: 4.5 mile run.
In managing diabetes (or managing health in general) it's often hard to say with confidence that a particular intervention is going to do more harm than good. The reason for this is that the human body is full of complicated systems which interact with one another in complicated ways. Anything you change in one of those systems is going to set off a cascade of reactive changes in other systems. After all those reactions and counter-reactions have played themselves out, and the dust settles, is the overall situation going to be better or worse than it was before? That's hard to predict.
For example, we know that injecting insulin reduces blood sugar. If the only issue we pay attention to is blood sugar, it looks as if we have a simple basis for deciding whether or not it's a good idea to treat Type 2 with insulin injections. But insulin has other effects as well, some of which may not be desirable. So the real question is not "does insulin therapy have advantages?"; the question is "do the advantages of of insulin therapy outweigh the disadvantages of insulin therapy?".
Insulin is known to have a "mitogenic" effect (that is, insulin tends to promote cell division). Anything that does that has the potential to increase the risk of cancer. On the other hand, insulin brings down blood sugar levels. Anything that does that has the potential to reduce the risk of cancer.
So which of these two effects predominates? If you treat Type 2 with insulin, does the glucose-lowering effect reduce the cancer risk more than the mitogenic effect increases it?
Medscape recently reported on a study in Hong Kong which set out to clarify this issue, by looking at 4623 Type 2 patients who were "naive to insulin" (that is, they hadn't used insulin yet when the study began). Some of these patients started insulin treatment, and their progress was tracked in comparison to those who did not receive insulin, over a 7-year period, to see what kind of impact the insulin had on their subsequent cancer risk.
Perhaps you were unaware that blood sugar levels affect your cancer risk at all. Discussions of diabetes management generally avoid the subject of cancer; there is more attention paid to other "complications" which are more common, and more firmly establed as diabetes complications. Nevertheless, there does seem to be a relationship between blood sugar and cancer. The authors of the Hong Kong study noted that cancer risk increase with increasing blood blood sugar, as illustrated in this graph, which plots cancer risk against Hemoglobin A1c test results:
Notice the slight "elbow" in the curve between 6% A1c and 7% A1c -- for whatever reason, whenever you look at the prevalence of any diabetic complication plotted against A1c results, things always start to get worse at a steeper rate once you get above 6.5% or so.
How does excessive blood sugar promote cancer? Perhaps in more than one way, but one of the factors mentioned by the authors of the Hong Kong study is increased "oxidative stress". In other words, sugary blood promotes harmful chemical reactions, and although the more famous consequences of those reactions are the problems we usually class as diabetic complications, such as neuropathy and kidney disease, cancer can be a consequence as well. Seemingly, bringing down the blood sugar level ought to reduce the cancer risk. But what if the mitogenic effect of insulin raises the cancer risk more than the glucose-reducing effect of insulin lowers the cancer risk?
Fear not: the study found that cancer risk was lower, not higher, in those who took insulin.
But here's the strange part: the people who took insulin, despite their reduced cancer risk, did not have a lower rate of death from all causes. If insulin offers an advantage in terms of cancer risk, it must have a disadvantage in some other area -- enough of a disadvantage to nullify the survival advantage from cancer reduction. The disadvantage, whatever it is, may relate to the tendency of insulin users to suffer episodes of hypoglycemia, but it could be something else entirely.
So once again we have the same maddening result that is seen with so many other pharmaceutical remedies (including statins and oral diabetes drugs): the remedy looks great if you focus on one narrow issue, but if you consider a broader issue (such as "not getting sick and dying"), you may be less impressed.
I'm not trying to say that insulin therapy is necessarily harmful or useless -- I'm only saying that the larger health impact of any kind of therapy can be extraordinarily complex and difficult to evaluate. We need to consider all the evidence we can get -- and more evidence keeps coming in, so we have to keep reconsidering it. The jury is always out.
Thursday, May 27, 2010
Fasting Glucose: 86.
Blood pressure, resting pulse: 124/78, 54.
Exercise: 4.1 mile run.
I was awakened slightly before dawn by a lightning and thunder. Extremely surprising weather for coastal California in late May. That it was raining at all seemed highly strange; I thought we'd already broken every local record for rain in May, and shouldn't have to face any more of it. Well, at least the rain was less heavy by the time I went running in it at lunchtime. Actually, running in the rain is starting to seem kind of normal to me. The only real problem with it is that soaking-wet clothes (especially shoes) are uncomfortable to move around in.
Strange as it seems, the time I spent running four miles in the rain today was by far the easiest part of my day. It was a day designed to make me think about the issue of job stress.
Stress is, of course, a huge issue for people with Type 2 diabetes, for four reasons:
Stress triggers a release of the "stress hormones", adrenaline and cortisol, which have an inflammatory effect on blood vessels. This kind of inflammation promotes the cardiovascular problems to which people with Type 2 are especially vulnerable.
Stress triggers hypertension, which has the same kind of inflammatory impact on blood vessels that stress hormones do.
The inflammatory effects mentioned above tend to reduce insulin sensitivity, and increase blood sugar levels.
Having to spend your whole life managing a complex and dangerous medical condition tends to stress people out.
According to a cardiologist I talked to once, one of the most potent causes of stress is simply time-pressure. If you want to stress somebody out, you don't have to put them in the middle of a life-or-death emergency. Simply giving them a task to do, and giving them just barely enough time in which to do it, is all that's required to get the stress hormones flowing and the arteries inflamed. It doesn't matter that the task isn't terribly important -- they could even be playing a game. If they're trying to get something done (even something trivial), and they aren't sure they have enough time to do it, they start to suffer from measurable, physical stress.
The world of work, in which people are routinely given tasks to do, and limited time in which to do them, is a stress factory by its very nature. And the strange thing is that those of us who suffer from stress there tend to make it worse for ourselves than it has to be. The more upset we become about deadline pressure, and about the obstacles that spring up in our path as we try to reach the finish line, the more we get into combat mode -- and go looking for trouble. After a while, everything looks like an obstacle, and everyone looks like a potential adversary. We start to get angry in advance over the trouble that we think people are going to give us. It's as if we're borrowing stress from the future, suffering now for what we expect will happen later. And we may decide that the trouble we foresee has already started, before we have any proof that it has.
This week I've been working on an assignment which couldn't have been better designed to stress me out. First of all, there was time pressure -- I needed to be done with it today. Second, it required me to do something complicated with software tools which I haven't used lately, and which were being extremely uncooperative this week. Third, there was confusion -- the task involved remote collaboration with someone in another country whose first language is not English, and whose written instructions were strewn with ambiguities and errors. Fourth, there was little opportunity to relieve the confusion, as time-zone problems and other issues made it impossible to communicate with my distant collaborator other than by e-mail. Fifth (and in some ways most important), his e-mail replies when I asked him for clarification always seemed to include remarks such as "as I said before", or "see my previous e-mail", as if the problem was that I wasn't paying attention, and not that he was unclear.
As my computer problems over the last few days became more complicated and more difficult to resolve (five people spent significant time helping me with these issues today), my frustration mounted, and for some reason I became especially fixated on what should have been a side issue -- those e-mails which seemed to be suggesting that if I was confused it was my own fault. Yesterday, before I left, I sent my distant collaborator a rather elaborate e-mail describing each issue I was confused about, and explaining to him in great detail all the points on which the information he'd given me was either self-contradictory or inconsistent with other data, so that it was truly impossible for me to know what was right if he couldn't tell me more explicitly what he'd been trying to say.
And I went home seething with resentment about how I imagined he would reply to this. I hated coming to work this morning, knowing I'd have to read his reply, and expecting it to be more of the same -- "I already told you that", etc. So when I got to the office and checked my e-mail, and saw that the most recent message received was from him, I opened it with a huge chip on my shoulder -- and my first reading of it seemed to confirm the worst. It opened with something along the lines of "Yes, go ahead and delete that command, it's obsolete, as you can understand from my previous e-mail". And I was furious, absolutely furious that he was doing it to me again! Why could he not be civil to me for once? Would it kill him to say, "sorry, I guess I wasn't clear about that"? Why did he have to insist on saying that I should have been able to understand this from his previous e-mail?
What with having a stroke over this and all, it took me some time to get around to reading the rest of my e-mail. And then I noticed that this wasn't the only message he'd sent me last night. His reference to "my previous e-mail" wasn't about the messages he'd sent me a few days ago, and which he knew had confused me. He was referring to an e-mail which I hadn't read yet.
So I opened that one, and its opening line said that he wanted to "shoot himself" when he looked over his earlier messages and finally realized that they contained errors which made them impossible to interpret. He apologized for having caused so much needless confusion and wasted time over issues which should have been simple.
I still had many other problems to get stressed out about today, including a computer network problem which was triggered by this morning's thunderstorm. But the one thing I was stressing about the most, the one thing that was pushing my blood pressure over the edge, was an issue which existed primarily in my resentful imagination -- and it wouldn't have been all that important even if it had been real.
And, by some miracle, the real problems I was dealing with all got solved, and I was able to meet my deadline and deliver the files on time.
I sent my collaborator an e-mail advising him not to shoot himself. I told him I never met anyone who tried it and said that it helped.
Wednesday, May 26, 2010
Fasting Glucose: 82.
Blood pressure, resting pulse: 119/78, 46.
Exercise: 4.1 mile run.
I was luckier with the weather today: although it looked like it was going to rain again during our run, it never did. And later in the afternoon the skies cleared.
I had a maddeningly frustrating afternoon (computer problems, just when I had a tight deadline and couldn't be dealing with computer problems), and I was very much stressed out by it. Then I left the office (or, to be more candid, fled the office as if it were a disaster scene) and emerged into brilliant sunshine. I decided there was only one thing to do: head over to Paradise Ridge.
That's a winery, located about 2 miles from my workplace, which serves wines by the glass on Wednesday nights in spring and summer. People bring food and sit on their balcony, sipping Syrah and watching the sun go down over the valley.
I know I'm supposed to be using meditation and yoga and exercise for de-stressing, but sometimes sipping Syrah and watching the sun go down can work, too.
He's back in the news!
The cycling world is abuzz over Floyd Landis and his abrupt change of story regarding doping. After years of denying that he was doing it, he now says that he was doing it, throughout his career in bike racing -- but that everybody else was doing it too (including Lance Armstrong).
Floyd Landis has repeatedly made it tough going for anyone who might have been tempted to sympathize with him. For example, a fellow cyclist (Greg LeMond) who had once confessed to Landis that he'd been a victim of child sex abuse, received an anonymous phone call in 2007, threatening him with public exposure of the child-molestation story if he testified against Landis at a hearing the next day. The call was traced, and it turned out that the call was from Landis's manager. Landis claims that he didn't authorize his manager to make that threat. Right.
I am unable to see Landis as one of the higher life-forms, but I don't dismiss his new accusations as fantasy. It is more likely than not that use of performance-enhancing drugs is just as widespread in bike-racing as it is in other sports. The individuals named by Landis may be doping and may not be, but it would surprise me if it turned out that none of them were. We've been through this cycle before, more than once, and so far the athletes accused of doping by others who were caught doping have turned out to be doping. And if the performance-enhancing drugs work at all, and their use is widespread among the top athletes, we almost have to assume that the people who win competitions are going to be the ones who had an unfair advantage going in.
This story strikes me as somehow relevant to the news announced yesterday by the Journal of the American Medical Association about progress (and lack of progress) on hypertension in America. Most publications spun this as a good-news story: more patients with hypertension have got it under control than before. But "more" is a vague comparator; what percentage of patients with hypertension have got it under control, you ask? 50%. Apparently that's a step up; ten years ago it was 31%. What counts as "under control"? Anything under 140/90.
Okay, so half of patients with hypertension have got it under control, and that's an improvement. But has there been progress on preventing the condition? Has the prevalence of hypertension gone down? Well, we're told that "the survey also indicates that little progress has been made in reducing the prevalence of hypertension". How much progress is "little progress", you ask? Well, the prevalence was 28.5% ten years ago, and now it's 29.0%. It takes a special kind of mind to see a slight increase in prevalence as "little progress" on reducing prevalence.
It may seem puzzling that control of blood pressure would improve but prevalence would not. Why aren't the things people are doing to control hypertension also preventing it?
Because people are not doing things to prevent it, that's why! Lifestyles are not changing for the better. The improvement in control, among those already diagnosed with hypertension, is simply the result of medication.
So American society at large has something important in common with professional athletes. At first glance, we seem to be doing better these days. But, on closer examination, it turns out that it's just the drugs.
Tuesday, May 25, 2010
Fasting Glucose: 80.
Blood pressure, resting pulse: 116/70, 53.
Exercise: 5.4 mile run.
A rainy day again! This is not normal for the month of May in these parts. Well, at least the rain is damping down the pollen, which had been causing me a lot of grief lately. This cloud has a pretty big silver lining.
When I started my lunchtime run today the rain had almost entirely stopped -- it was barely sprinkling, and I thought the rain was probably over for the day. Wrong! The rain started up again as soon as I was far from shelter. It didn't bother me that much, but I did get a little bit chilled. After I got back to my desk I had to put on a sweater (I don't usually feel the need for that in the office), and now that I'm home, I'm wearing a heavy sweatshirt, and drinking a great big cup of hot tea. I don't think I did myself any harm -- I wasn't that chilled -- but I don't want to take any chances. Last year at this time I managed to get an unseasonable cold, and I don't want to do that again.
Sometimes I have to remind myself that my exercise program should be making me feel better. If it leaves me injured or ill, I'm not doing it right.
Of the many effects that exercise has had on me, over the nine years or so since I accepted that I really have to do it, one of the most striking has been the reduction in my resting heart rate (also known as RHR). These days, my RHR is usually below 60 beats per minute (even in the low 40s when I'm lying down). Before I started exercising, it was in the 80s.
This has to be the result of exercise, because I haven't been doing anything else that could have caused a gradual reduction in my RHR. (I'm not taking any medications that could reduce my heart rate, for example.)
A reduced RHR is considered a good sign, because it means you now have a more robust cardiovascular system. Your heart can move the same blood volume without having to work as hard. (When your heart can move more blood per contraction, it doesn't have to contract quite so frequently, so your heart rate goes down.)
This view of the matter represents RHR as rather incidental -- a side-effect, important only as an indicator of more important matters. But what if RHR has its own importance, independent of other things?
Today, Medscape published an article (originally form the American Heart Journal) entitled Elevated Resting Heart Rate is an Independent Risk Factor for Cardiovascular Disease in Healthy Men and Women. The article reports on a large study in Finland which attempted to separate the effect of high RHR from other factors which have an impact on cardiac health, to see if RHR, all by itself, is a predictor of CVD. Turns out that it is.
For reasons best known to Medscape, the actual data from the study is presented in graphs the size of postage stamps; here is one which I have blown up to a state of near-legibility. This particular graph compares death rates from coronary heart disease in men, by RHR category. The lowest rates are in men with an RHR below 60. The death rate increases gradually as RHR increases, but increases faster once the heart rate is over 80.
Other graphs (for deaths from other causes) show a similar pattern. The graphs for women show lower death rates overall, but nevertheless the rates increase as RHR increases. (In fact, it increases at a steeper rate in women than in men, even though the overall rate is lower.)
Now, the big question is obviously: "why"?
Why does a higher resting heart rate increase your risk of death from cardiovascular disease, coronary heart disease, and other causes -- independently of any of the other factors we usually associate with cardiac risk?
The study's authors say, "The mechanism through which elevated RHR exerts its deleterious effect is unknown." However, they do throw out some suggestions about what elevated RHR might do to people:
It may cause a predisposition to ischemia (blockage).
It may promote plaque rupture (it's when plaque tears loose, wounding the vessel wall, that you get a blood clot).
It may promote atherogenesis (placque buildup) by increasing the absolute number of sheer stresses affecting the vessel wall.
It may promote arrhythmia (various lines of evidence suggest that this may be an especially important factor).
Actually, the first of those bullet points sounds like nothing more than a summary of the second and third, but that's the way the authors present the issues, and who am I to second-guess them?
So, anyway, it's very bad to have an RHR above 80; it's very good to have an RHR below 60 (and if you want to make that happen, exercise is how you do it). All things considered, it's a good thing that I went for a run today despite the rain.
Monday, May 24, 2010
Fasting Glucose: 89.
Blood pressure, resting pulse: 124/78, 50.
Exercise: 4.6 mile run.
Time to break out the baby shampoo. Bear with me, I can explain.
Lately I had started thinking that my allergy season was drawing to a close, which is why I planned a hike yesterday, in grass-covered hills, without even worrying about whether this might cause me any trouble.
I had been considering signing up for the Lynch Canyon Trail Run next month, but the terrain sounded so daunting in what I read about the place that I thought it would be wise to try walking there before I tried running there. So I went by there yesterday, to check the situation out. Sure enough, there are some mighty steep hills.
I enjoyed it as a hiking location, certainly. It was bigger and prettier than I had expected. There was still a fair amount of green clinging to the hills (I expect it will all be gone very soon, so it was good to see it while it was still there).
However, because the location does not attract a lot of visitors (I saw some hikers and a couple of equestrians, but I doubt that more than 15 of us were on the property during the entire afternoon) the paths are not exactly well-worn. The grass and weeds growing on many of the paths tend to conceal such hazards as gopher holes and cow-pies. I stepped (actually, I slid ) in a couple of the latter. This made me wonder if running several miles on such trails would be a good idea.
I liked the scenery, and the pleasure of hiking in a place so little-known and little-visited. But I'm tending to see it as a hiking location, not a running location. I'd like to go there again, perhaps next February (when the hills are green again, but the air is not yet swarming with pollen).
It was quite windy yesterday, and I was walking through tall grass and weeds a lot of the time -- both of which are high-risk situations in terms of allergies. By the time I was heading back to my car, I began to realize that it wasn't just my eyes and nose that were irritated by all the pollen and other plant matter flying about. My forearms, lower legs, and neck were broken out in hives (and they stayed that way for the next eight hours or so).
I wasn't incapacitated by all this -- in fact, I went to a dinner party at a friend's house later. But I wasn't at my best, either, and I had to take my contact lenses out because I could no longer tolerate them (fortunately, I had my glasses with me, so I could see to drive home).
I woke up this morning with eyes profoundly irritated and swollen, and I still couldn't put my contact lenses in. However, the weather took a turn for the cold and damp today (never quite raining, but hovering on the edge of it), and this helps a lot if you have allergies. I was eventually able to put my contact lenses in, and when I went for a run at lunchtime, I had no allergy problems as a result.
But tonight I went to the store and bought some baby shampoo. This is a trick you need to know about if allergies are bothering your eyes. The eybrows and eyelashes tend to collect pollen over the course of the day, and at night the stuff goes to work on irritating the hell out of your eyes, so that you woke up with eyes red and swollen (like mine were this morning). The best solution is to get some baby shampoo and a washcloth and some warm water, and give your eyes a good solid cleanup before you go to bed. You wouldn't want to do this with regular shampoo -- it's too irritating to the eyes. Lately I haven't been having enough eye trouble to care (or even notice) that I'm out of baby shampoo, but tomorrow morning I want to wake up with my eyes feeling about a hundred times better than they did when I woke up this morning. So it was worth going downtown to buy some.
I picked up a copy of Share Guide: The Holistic Health Magazine , a local free semi-monthly, and was delighted to find that one of its articles is entitled "Get Pregnant the Easy Way, with Acupuncture". Oh, so that's what you young people are calling it these days?
Of course the article is about how to use acupuncture as a cure for infertility, not as a substitute for making the beast with two backs (hey, that's what Shakespeare called it in Othello -- I'm merely quoting).
But this is typical of my relationship with the whole world of "alternative" and "holistic" medicine: I can't for a minute ignore what is absurd about it, and yet I can't ignore what is heartfelt about it, either. People need something that modern medicine isn't giving them, and however ridiculous they may make themselves as they grope awkwardly toward a solution to that poblem, I am forced to admit that the problem is a serious one, and I'm willing to consider the possibility that, by groping awkwardly toward a solution, they may now and then stumble upon something useful. Even a blind squirrel finds a nut once in a while.
The internet is now home to all sorts of lifestyle gurus who are offering themselves as living proof that some unusual dietary restriction will transform your health in amazing ways. They photograph themselves exercising and posing, to show you how much leaner and more energetic you could be -- if only you were doing what they are doing.
Unfortunately, they then go on to explain their theory about why what they're doing is the best approach -- and the explanation is so absurd, or is expressed so naively, that you can't keep a straight face. But does that mean that what they're doing isn't working for them, or does it merely mean that they haven't been clever enough to figure out why what they're doing is working for them?
The supply of crackpot theorists may be more generous today than it ever has been in the past, now that the internet has given a forum to ever single one of them. But that doesn't mean that what they're doing is necessarily the wrong thing to do. If you've found something that works, it doesn't matter very much that you found it by stumbling upon it, or that you really don't understand what it is you've stumbled upon.
It isn't unreasonable, I hasten to add, to take a skeptical view of people who make extravagant claims backed up by gibberish. I just don't want to ignore potentially valuable discoveries on the grounds that the wrong sort of people discovered them.
Saturday, May 22, 2010
Fasting Glucose: 84.
Blood pressure, resting pulse: 121/77, 59.
Exercise: 5.3 mile run.
This my third day in a row with a fasting result of exactly 84. Does this mean that my blood sugar has stabilized at 84? No, it means that my blood sugar has been somewhere within shouting distance of 84 for the last three days, and random variations in the test strips happened to make the results look like 84.
However, being within shouting distance of 84 is good enough for me.
Without having had nearly enough sleep, I went to a meditation workshop this morning, and this created a bit of a problem for me. It's fairly easy to achieve inner peace when you're dozing, but it's not easy to maintain awareness at the same time. That's what's hard about meditation: you're supposed to have it both ways. Heightened awareness of every sensation (including, perhaps, the ache in your back that's happening because you're sitting up straighter than you're normally inclined to do) is not supposed to disturb your equanimity -- and neither is your equanimity supposed to interfere with your heightened awareness. This morning, my equanimity kept going too far, so that the only thing I was aware of was the series of little two-second dreams I kept having, as I hovered uneasily between consciousness and sleep.
I confessed the problem I was having, and the fellow giving the workshop offered me some suggestions on how to cope with drowsiness while meditating. I finally had to try out his most extreme suggestion: meditate standing up. I was afraid that standing up straight without moving, for 20 minutes, might be a little hard to do. It was hard to do, but the fear of falling kept me awake, and that was useful. Of course, it would have been even more useful to have had enough sleep before the workshop, but things just didn't work out that way.
I was planning to go outside for a run this afternoon, but first I wanted to have a nap. By the time I finally decided I was ready to run, it was late in the afternoon, and as I was getting dressed for it (not being aware that the weather outside was going through a sudden change), I heard a surprising sound: rain on the skylight. And then a sharper and more surprising sound: hailstones bouncing on the skylight.
What? Huh? I hadn't realized that was even a remote possibility today. I didn't feel like running in a hailstorm, but my health club closes pretty early on the weekend, and I was running out of options fast.
The thing about hailstorms, at least in this area, is that they tend to be brief and isolated phenomena, typically followed by a rapid clearing. Maybe if I waited a little while, things would improve -- before it got dark.
I was right: by 6:30, it was sunny again, and I had a beautiful run. I took my camera with me.
The hardest part was climbing this insanely steep hill...
...but climbing it was worth it, because of the views you get from the top.
A lot of people have no idea how pretty their own neighborhoods can be, because they don't make a habit of running or cycling, or even walking. My advice is to get outside, if only for the sake of your inner peace.
Friday, May 21, 2010
Fasting Glucose: 84.
Blood pressure, resting pulse: 118/80, 43.
Exercise: rest day.
I decided to take my rest day today instead of tomorrow, because I was short of time. I had to leave work a little early, to get down to Oakland in time for the A's/Giants game. It was a family event: my dad was there, and some of his many progeny -- including a grandson and great-grandson.
And what a relief the clear weather in the evening was! It had been cloudy all day, with occasional light rain, and I wondered if the game would be canceled -- or if it would be played, but under miserable conditions. But the skies began to clear about an hour before the game, and all was well.
After it got dark I began to be glad I'd brought a warm jacket and stocking cap, but I was quite comfortable. The Giants were less comfortable: to be honest, it was a pretty uneven contest. But I shouldn't criticize them, because I'm not absolutely sure I could have done any better myself.
When people are quarreling about nutrition (as they certainly have been the dLife forum of late), they like to use the terms "high" and "low"-- as in "low carb" and "high fat". The trouble with these terms, as applied to diets (particularly weight-loss diets) is that they refer to ratios rather than absolute amounts.
We tend to take it for granted that the ratio of one nutrient to another is what matters. What percentage of your total calorie intake should consist of fat, carbohydreate, protein? Often diets are described simply by three numbers, representing those proportions. But the proportions, by themselves, don't indicate how much you're eating of anything. What if it's the absolute amount of a particular nutrient that matters? Or even the absolute amount of all nutrients?
A weight-loss diet which some people call "high carb" might actually involve cutting carbs -- but cutting fat more. If you're losing weight at all, you're probably getting less of everything than you used to.
My initial, rapid weight loss after diagnosis was achieved by means of a low-fat, vegetarian diet. I'm not sure it would be accurate to call it a high-carb diet, though. It was wan't a high anything diet, trust me! I was eating more vegetables than most people would, but I wasn't eating a lot of starch. I was losing weight on it at a pretty rapid clip (2 or 3 pounds a week). It wasn't easy, I was hungry a lot, and it wasn't a diet I could stay with for the long term. It was just a means to an end. I wanted to drop about 50 pounds as fast as I could. That was how I chose to do it. I'm sure there are other ways to do it, and for some people those other ways would be better.
During that phase of rapid weight loss, my blood sugar gradually dropped down to normal, or close to normal anyway, and when I next had lab work done my LDL and Triglycerides (initially 147 and 150) were cut in half. But why did they drop so much? There could be various reasons for it. Maybe it was simply the fact that I'd lost a lot of weight. Maybe it was because I was exercising a lot more than I ever had before. Even if it was my diet that made the difference, I don't know if it was because the particular ratio of nutrients I was taking in was favorable, or if it was because I was taking in less of a particular nutrient, or if it was simply that I was eating less food altogether.
One thing the diet didn't help me with was HDL, which rose only from 32 to 33. (In the years since it has climbed gradually to 54; my doctor attributes that to consistent exercise over a long period, and not to any particular dietary change.)
Since that initial weight loss of 50 pounds, I have very slowly lost 20 more, and I have tried out a variety of adjustments to my diet. At this point it's certainly not strictly vegetarian (although I emphasize plant foods) and it isn't low-fat either. I haven't noticed that changes in my diet produce any obvious change in my lab results, but I do notice that my blood sugar starts edging up if I take in more carbs, and my weight starts edging up if I take in more fat. It's hard to fine-tune the proportions of these things. Eating less food in general seems to be the most effective way to solve the problem. The only trick is learning to like eating less food!
However, all of these observations apply to me specifically, and not necessarily to everyone. In fact, I'm pretty sure that many other people could have done exactly what I did, with completely different results. Individual physiology varies too much for us to be able to make one-size-fits-all rules. We have to experiment enough to find out what works for us.
But there's the catch: what do we mean by "what works for us"? We can only evaluate a diet in terms of things we can easily measure: body weight, blood sugar, lab results. What we can't evaluate is the long-term impact of a diet on such matters as cardiovascular health and cancer prevention. Whether I'm doing the right thing by my arteries is something I can't be sure about. I'll just have to wait and see. And, because no one really wants to wait and see (we want answers!), people create theories about what constitutes a healthy diet, and have passionate arguments about the subject.
But before they get too deeply into that, maybe they should decide what the words "high" and "low" mean.
Thursday, May 20, 2010
Fasting Glucose: 84.
Blood pressure, resting pulse: 117/78, 47.
Exercise: 4.6 mile run.
After yesterday's run in the rain (a light rain, admittedly -- but still!), today's clear and sunny weather was especially welcome. One of my running buddies (who's been away for a few weeks) was back today, which meant I couldn't slack off on my running pace, as I usually do when nobody's looking. Our route today was half a mile longer than what I ran yesterday, and we still completed it in less time.
The immature section of my brain feels that the ideal running buddy is one to doesn't want to go any faster than I want to go. The mature section of my brain (it may be small, but it's in there somewhere) realizes that the ideal running buddy is one who wants to go faster than I want to go, and perhaps a tiny bit faster than I can go. It's the same with music: you don't learn anything from the people who aren't any better than you.
I used to do organized exercise events (usually footraces) about once a month, but late last year I got out of the habit. After the half-marathon last Halloween, I didn't sign up for anything else until I did the Bay to Breakers 12K race last Sunday. But Sunday's race felt good to me, and running it reminded me of what I miss about these events.
First of all, I like the slight sense of drama that surrounds an organized event of this kind. You have to register for it, get up early in the morning to travel to it, and then stand around shivering as you wait for it to start. And always you have that slight feeling of nervous tension, as you ask yourself if you're really ready for this. Did you drink enough water beforehand? Or maybe too much? Did you eat the right kind of breakfast, and did you eat it far enough in advance of race time to ensure that you're not going to have an upset stomach during the run?
Also, I like to be around a big crowd of active people -- I feel as if their energy is contagious, and I'll absorb some of it from them.
And if the event is held in a pretty location (and most locations are at least a little bit pretty, when you're outside exercising in them at 8 AM), I enjoy being there, seeing the sights and breathing the fresh air.
And when the race is over, and I head home, I get a satisfying feeling at having gone somewhere and completed a big physical effort by the time most people, on a weekend, are just getting around to getting dressed.
So, anyway, I want to get back into my old routine of doing an organized event at least once a month. I've just done one for May, of course, so now I'm trying to figure out what I'm going to do in June. Here are three events I'm looking at...
On Sunday, June 5th, there's "Hit the Road Jack", a 10K race that begins and ends at the plaza in the town of Sonoma. That's a big, popular event which I've done a couple of times.
Reasons for choosing this race: (1) lots and lots of runners, so it's a good event in terms of contagious energy, (2) I usually know other people running in this race, and (3) last year I foolishly ran it when I was still recovering from a cold, and I'd like to erase the bad memory of how that went by doing it over right.
On Sunday, June 13, there's the Fitch Mountain Footrace in Healdsburg -- also a 10K. I've done this one a few times before, too.
Reasons for choosing this race: (1) the route is prettier than the route in the Sonoma race, and (2) it's a little easier to get to.
Finally, on Saturday, June 5th, there's the Lynch Canyon Trail Run, in the hills between Vallejo and Cordelia. This race offers two distances: a 10K and a half-marathon. I've never done this race before.
Reasons for choosing this race: (1) it would be something new -- I've never done this race, or any other race that was in this type of landcape, (2) it would be off-road, and I like that kind of running, and (3) it would be a good challenge, as there's quite a lot of hill-climbing to do even if you choose the shorter route.
The Lynch Canyon race seem like a more exciting prospect to me than the other two. However, it has its disadvantages. For one thing, it's a mighty long drive from where I live, so I'd have to get up very early in the morning, and then I'd have a long drive home after the race. Also, the race might be a bigger challenge than I'm ready for. The hills in that race must be brutal -- I noticed that the course record, for the 10K distance, is about 11 minutes longer than I would expect for a 10K. Also, I'm not sure I would drive that far just for a 10K race; unless I was doing the half-marathon route, I wouldn't feel as if it was worth traveling that far to the event. But a half-marathon in that kind of terrain would be a pretty serious ordeal. I'll have to think it over, and make sure I really feel ready for this one!
Wednesday, May 19, 2010
Fasting Glucose: 81.
Blood pressure, resting pulse: 121/78, 48.
Exercise: 4.1 mile run.
That's more like it: fasting result of 81 this morning. I knew I could bring it down.
Yesterday I discussed the cardiac-risk algorithm that came out of the PROCAM study. The PROCAM people take a not-very-nuanced view of the role played by glycemic control (and by diabetes in general) in causing cardiovascular disease. In their point-based risk formula, they give you 4 points for having been diagnosed with diabetes in the first place, and then tack on an additional 3 points if your fasting average is above 120 mg/dl. Those are the only adjustments available to you under the formula: either you're a good diabetic with 4 points, or a bad diabetic with 7 points. They feel justified in taking this somewhat crude approach because the PROCAM data seemed to show that being diagnosed with diabetes raises your risk, and that much of this added risk remains in place even you get your diabetes under good control (admittedly, their apparent definition of "good control" as a fasting average under 120 is very much open to challenge).
Other studies have tried to take a closer look at the impact of glycemic control (as measured by the Hemoglobin A1c test). A study that I referred to on May 7 found that risk increased with A1c values, and that the risk profile presented a "J-shaped curve", increasing more and more steeply for A1c results above 6%. Unfortunately, the authors of that study didn't take much care to express themselves clearly, with the result that I'm not sure whether the "risk" they were describing was actually the risk of cardiovascular disease, the risk of death from various causes, or even simply the risk of being diagnosed with diabetes. (I hope it's not the latter; doing a study to compare diabetes risk with A1c results would be about as revelatory as doing a study to compare body weight with clothing sizes.)
"The increased risk of death among men with diabetes was largely explained by HbA1c concentration. HbA1c was continuously related to subsequent all cause, cardiovascular, and ischaemic heart disease mortality through the whole population distribution, with lowest rates in those with HbA1c concentrations below 5%. An increase of 1% in HbA1c was associated with a 28% (P<0.002) increase in risk of death independent of age, blood pressure, serum cholesterol, body mass index, and cigarette smoking habit; this effect remained (relative risk 1.46, P=0.05 adjusted for age and risk factors) after men with known diabetes, a HbA1c concentration >7%, or history of myocardial infarction or stroke were excluded.
18% of the population excess mortality risk associated with a HbA1c concentration >5% occurred in men with diabetes, but 82% occurred in men with concentrations of 5%-6.9% (the majority of the population).
Conclusions: Glycated haemoglobin concentration seems to explain most of the excess mortality risk of diabetes in men and to be a continuous risk factor through the whole population distribution. Preventive efforts need to consider not just those with established diabetes but whether it is possible to reduce the population distribution of HbA1c through behavioral means."
These are startling claims: most of the excess risk was found among men not diagnosed with diabetes, but with A1c results above 5%. Any increase in A1c results adds to your risk, and an increase from 5% to 6% is enough to increase your risk by 28%.
However, the data tables included with this study present a more confusing relationship between A1c results and risk. As the tables are hard to read in their original form, here's my easy-to-read synopsis of the parts I find interesting:
|A1c Range||<5%||5 - 5.4%||5.5 - 6.9%||>6.9%|
|Cardiovascular disease, relative risk||1.00||2.53||2.46||5.04|
|Ischemic heart disease, relative risk||1.00||2.74||2.77||5.20|
If we only look at the lowest and highest of the four A1c ranges, the picture is clear: your risk is five times as high if your A1c result is 7% or more, as compared to the risk if your result is below 5%.
However, what about the two middle ranges? Shouldn't there be significantly more risk in the higher of the two?
If A1c results are "continuously related" to risk, as described in the summary of the study, then the results in the data table ought to progress upward in a way which they are clearly not doing.
However, it may be that I have misunderstood their presentation of the data. It may also be that heart attacks happen uncommonly enough (even in people "at risk") that it's very hard to do a study large enough to capture the number of heart-attack histories it would take to illustrate the probability pattern convincingly.
I still believe, of course, that A1c reduction is a worthwhile goal for anyone with diabetes. However, it seems to me that the data tables presented with this study seem to provide confirmation, not refutation, of the PROCAM study's conclusions: that elevated cardiac risk comes with being diabetic, and that achieving good glycemic control doesn't seem to eliminate much of that risk -- unless you bring your A1c level a lot farther down than most people with diabetes dream of doing. (Of course, this may simply mean that diabetes patients need to start dreaming big).
Either you think this kind of thing is funny or you don't, but this site has a remarkable collection of images from a Chinese pirate edition of one of the Star Wars movies. For reasons which are a little unclear, the disk comes complete with subtitles which translate the Chinese-language version of the movie back into English -- sort of. If translated prose is funny, twice-translated prose is twice as funny. Not even the film's title survives the process in recognizable form:
Other phrases that lose something along the way include "may the force be with you"...
...and "the Jedi Council".
Here are some more examples...
Tuesday, May 18, 2010
Fasting Glucose: 96.
Blood pressure, resting pulse: 116/75, 54.
Exercise: 5.5 mile run.
Dammit, fasting test up instead of down today! Well, it was a light exercise day yesterday, and looking back on it I just took in too much carbohydrate.
I tried hard to make up for it today, by eating lower-carb meals and doing an exceptionally hard run at lunchtime (steep hills and a pretty fast pace). I'm pretty sure that tomorrow's result will be better, but if it's not I'll just have to work on it some more.
My constant munching at the party after the
race on Sunday is probably having a lingering effect. The trouble with big,
public exercise events is that they make you feel entitled to eat whatever you
want at the celebration afterward. The day before the race I didn't exercise at
all, but I was very conscious of the need to eat light for that reason, and my
fasting test on the morning of the race was 82. Runing 7.5 miles may
have entitled me to eat a little more than I had eaten on Saturday, but not
as much more as I actually treated myself to.
Maybe it's fate that caused The Onion to publish the following mock article the
day after the race:
Woman Constantly Treating Herself For Once
RICHMOND, VA -- After making it through her 63rd consecutive longest week ever, project manager Maureen Peltier decided on Friday to once again treat herself to the kind of pampering everybody needs to indulge in from time to time. "Why not? I deserve it," Peltier said of the past week's pedicure, trip to the spa, box of Godiva chocolates, and two glasses of chardonnay drunk during a lunch meeting. "There's nothing wrong with spoiling myself now and again." On the way home from the spa, Peltier who decided that she had earned the right to go off her diet just this once, pulled into a McDonald's, and ordered the usual.
They don't actually know me, those people at The Onion, and yet somehow they do.
There's been an interesting discussion happening on the dLife forum about the risk of CVD (cardiovascular disease) and why it's so high in people with diabetes, almost regardless of what kind of medical care they're getting.
Roughly speaking, your risk of a heart attack is about 2.5 times higher if you have diabetes than if you don't. This is independent of other risk factors commonly associated with diabetes, such as hypertension and high cholesterol. That "2.5" multiplier seems to come out of the PROCAM study (also known as the Prospective Cardiovascular Munster Heart Study, or more simply as the Munster Heart Study). Other studies have found the multiplier to be as low as 2, or as high as 4, but 2.5 seems to have won general acceptance as a good average value.
The PROCAM study tracked a large number of middle-aged men in Germany over an extended period to figure out what factors correlated with heart disease, and how much impact those figures had. Later, women were studied as well, but most of the data comes from studies of men, and the conclusions about heart attack risk are specific to men -- which is good news for women, because the risks quoted for men can be divided by four for women (at least for women under 65; things are not quite so rosy after that).
The PROCAM study led to the PROCAM algorithm -- a formula for figuring out how likely you are to have a heart attack in the next 10 years. I tried using the algorithm myself, plugging in recent lab results and other information about myself to total up my points and figure out where I stand in the high-stakes game of cardiac risk:
|Systolic Blood Pressure (Range)||120/129||2|
|Average Fasting Glucose||88||0|
|Heart attack in family history||No||0|
My PROCAM score (25 points) means that my risk of having an "acute coronary event" in the next ten years is 1.3%. Reassuringly low, I'd say. The lowest score you can possibly get, for a man of my age, is 18 points, corresponding to a risk of 0.6%. To be at 1.3% instead of 0.6% is not ideal, but it's not going to keep me awake tonight.
I chose to describe my systolic blood pressure as being in the range of 120/129, because it's often above 120 -- although it's probably more often below 120 (as it is today). However, giving myself credit for being below 120 would only have removed one point from my total, and I wasn't sure I was entitled to it. Probably my PROCAM score of 25 is about right.
However, I was wondering what my PROCAM score would be at this point if I had not made any improvements in the test results I was getting at the time of my diagnosis in early 2001. I plugged in those numbers, and here's what I got:
|Systolic Blood Pressure (Range)||130/139||3|
|Average Fasting Glucose||~174||3|
|Heart attack in family history||No||0|
This PROCAM score (54 points) would have corresponded with a risk of 16.7% rather than 1.3%. In other words, my cardiac risk would have been more almost 13 times as high if I had not made these improvements.
By the way, being a smoker would have raised my score to 63 points, and my risk factor to 34%. One more reason to be glad that particular habit never attracted me.
There are some interesting details about the PROCAM algorithm. One is that it ignores body weight -- you don't get any extra points for being fat (I guess they figure obesity will be captured by the other factors, because if you're fat you're not likely to be free of problems with lipids and blood pressure).
Another interesting detail is that the algorithm awards you 4 points for being diagnosed as diabetic, regardless of how well you're controlling your glucose. The PROCAM study concluded that being diabetic at all was an independent cardiac risk factor, even if you maintain good control. However, they don't seem to have looked at many cases in which people had diabetes and did control it well; later studies have found that really good control can bring the risk factor down, and I'll discuss those tomorrow (or soon, anyway).
For whatever reason, the PROCAM study didn't include a risk factor for the unhealthy effects of spending too much of your time writing a diabetes blog. I'm afraid it's probably worth about 5 points, though.
Monday, May 17, 2010
Fasting Glucose: 93.
Blood pressure, resting pulse: 125/81, 47.
Exercise: 30-minute gym aerobic workout; yoga class in the evening.
Yesterday was the Bay to Breakers race in San Francisco, and as a running experience (as if that's what the event was about!) it was good for me this year. Running felt comfortable. The course seemed shorter and easier to me than in previous years.
It's a big event -- the local paper estimated 60,000 people. Not a good race to do if you get uncomfortable standing around in a big crowd waiting for the race to start.
You also had to have a certain tolerance for hanging around with nudists, as those people have become bolder lately, and they are no longer content to dart in from a side street and join the race after it starts; several of them were right there with us from the very beginning. The cool, overcast weather, which is actually ideal for running, was not necessarily ideal for standing about with no clothes on. Some of them men were not "showing well", if you follow me. It must have been a relief to them when the race finally started and we could get moving and warm up.
Whatever it is that drives people to want to run across San Francisco with no clothes on, it must be a very powerful thing, because they don't get a lot of encouragement or respect. People snicker at them, and make disheartening remarks such as "No mirrors at home, eh?". And if there's any question in your mind about whether running motions tend to be flattering or unflattering to naked people (especially from the standpoint of those who are stuck running behind them), I can set your mind at rest on that issue.
After a mile or so, it begins to look as if the crowd is spreading out and starting to leave you more room to maneuver. This conclusion is premature...
...because the runners start bunching up again when they get to a hill. A lot of them slow down, causing a logjam.
The police always say before the race that they are going to arrest the nude runners, but on race day they always decide to look the other way while the nudists go running past them. I'm not saying I'd do any different in their position. It's hard to see the oft-threatened "crackdown" working out well in practice.
Besides, the cops aren't the only ones looking the other way. Averted eyes are as much a part of the Bay to Breakers experience as anything else is.
The run gets a lot nicer once you're off the city streets, and into Golden Gate park.
However, the down side of going into the park is that that's where the angry preachers wait for us with megaphones, and explain to us whom God hates (mainly us, it seems) and what happens to the people God hates (eternal hellfire). Always a nice sentiment to share with passing strangers in the park on a Sunday morning. They weren't just yelling at the nudists, either. Apparently God hates all runners equally.
A somewhat more encouraging sign: getting close to the finish.
Can it be....? Yes! Our first glimpse of the ocean in the distance.
We're definitely seeing the ocean now. And other big green things.
And then the finish line at Ocean Beach.
I wasn't concentrating on speed. I was trying to photograph the race while running it, and sometimes I had to stop (or at least slow down) in order to get a reasonably steady shot. Even so, I finished a little faster than I had done before.
The event is, to put it mildly, not taken absolutely seriously everyone who shows up for it. For a lot of people it's not really a race; it's a party which happens to take place in the middle of city streets. My theory is that the event is a magnet for inhibited people who want to become uninhibited for a day, and find that (paradoxical as it seems) it's easier rather than harder to accomplish that when you're in the middle of a great big crowd. Hence the runners in outlandish costumes (sorry; I didn't get any good shots of those) and the runners in no costume of any kind.
My theory about inhibited people overcompensating for their inhibitions may be questionable in the case of the naked runners, in part because many of them had all-over tans, suggesting that this wasn't quite as special an occasion for them as I'm making it out to be. But maybe those tans came about because they spent the last month in tanning boths getting ready for the big reveal yesterday, and they merely wanted to make it look as if this nothing new for them.
My finish time was 1:14:42. Is that good or bad, you ask? Well, it depends on how you look at it. Most serious runners would probably expect to be able to finish a 12K race in less than an hour. And the elite competitors, who were placed at the starting line so that they wouldn't have to fight their way through an army of people stumbling around in funny costumes, would surely expect to finish it in less than 40 minutes. In fact, Sammy Kitwara, who won the race, finished in 34:15. And Lineth Chepkurui, the fastest female running in the race, finished in 38:15, setting a new women's world record. (I probably don't even need to mention this, but both of them are from Kenya.)
Considering that I crossed the finish line 40 minutes after the fastest male runner, and 36 minutes after the fastest female runner, you might think there would be no way to see my performance yesterday in a positive light. Oh, but there is!
First of all, in all fairness, it's not easy to achieve a fast pace in the Bay to Breakers race. The route is both hilly and extraordinarily crowded. Furthermore, the party atmosphere of the event pretty well guarantees that the people in your way are going to be hard to get around. They tend to be running side by side with their friends, often forming a kind of chorus line, and they're too busy chatting with each other and goofing around to notice (or care) that they're blocking people behind them who want to go faster. This may not an issue for the Kenyans up front, who have had a path cleared for them, but it's an issue for the common herd.
So, the question to ask is not how fast did I go compared to elite runners with nobody in their way. The question to ask is how fast did I go compared to all of the thousands of people who participated in the race?
Well, I was in the top 20% of all participants, the top 30% of male participants, and the top 25% of male participants in my age group. That's a lot better than I would usually expect to do in a big race. However, I did that well partly because many of those other participants were walking rather than running. Even so! If 75% of guys my age finished after I did, I feel entitled to see my performance in a positive light. Also, I was faster than I'd been in previous years, and that's always a good thing.
After the Bay to Breakers race: the Bay to
Breakers party. And too much to eat, I'm afraid, which is why my fasting test
was up a bit at 93 (it had been 82 the previous morning). There's a limit to how
much self-indulgence a 12K footrace entitles you to, and I may have exceeded
that limit. But 93 isn't bad, it just isn't as good as I'm capable of doing.
Friday, May 14, 2010
Fasting Glucose: 85.
Blood pressure, resting pulse: 116/79, 56.
Exercise: 5.2-mile run.
Not bad weather today, here in Sonoma County. A beautiful run at lunchtime, and dinner outdoors.
Then to Healdsburg for the last in a series of
chamber-music concerts, this one featuring the Aviv String Quartet, a
much-praised ensemble from Israel. They were stunning players.
(They also had some stunning instruments -- everything but the viola was over 300 years old, and the cello was a Stradivarius. Can you imagine traveling around the world carrying something like that with you? I'd be a wreck worrying about it.) In addition to the Haydn and Beethoven compositions on the program, which were familiar to me, they played a very obscure piece by the unjustly-neglected Hungarian composer Erno Dohnanyi (his Quartet No. 3, composed in 1926). It was the high point of the concert, I thought -- a great but forgotten work, and clearly a very difficult work to play, but they brought it off brilliantly. At a reception after the concert I spoke to Sergey Ostrovsky, their first violinist, and he told me that tonight was the first time they had every played the work in public; they're playing it again in Los Angeles this weekend, and then going into the studio to record it. Well, I'd say they're ready for their closeup.
On Saturday, a little yellow light in the shape of a wrench showed up on the dashboard display of my Honda Civic. It was a maintenance reminder; next to it was a message reading "A1" (indicating the type of service that needed to be done next) and "Oil Life 15%" (indicating that the service would be need to be done fairly soon). So, I called up the dealer, and they told me what the "A1" service involved (not much -- mostly an oil change and tire rotation). I made an appointment to have that done, and this morning I took the car into the dealer. Their shuttle service gave me a ride to work, and only a few hours later they called to say they were done with my car, and to arrange for the shuttle to take me back there. It was all very easy.
It's too bad we don't have something like that for the human body. Here's how I picture it: one day you feel a sudden tingling in your wrist, you look down at it, and you see a little temporary tattoo that says "X3, 30 Days". You call up the doctor's office, tell them you need the X3 service within the month. They explain to you what X3 entails -- some blood work first (mainly lipids and hemoglobin A1c), with a follow-up office visit if anything unusual shows up on the lab report. So you go in to the lab to have your blood drawn; later they call and tell you that the results were normal, so you're good to go until your next service is due in September (that will be the T8 service, which is more involved and will include a physical exam).
But maybe, before your T8 service falls due, you feel a more intense tingling in your wrist one day, you look down at it, and you find that this time the tattoo is red, and it says "ALERT 2447". Uh-oh! You call up the doctor's office; they say that "2447" means "partial occlusion in a coronary artery", which means you're at risk for a heart attack, and you need to come into the office to have some tests done, and to discuss treatment options if the tests confirm the problem.
Or, you notice one day that a small black star has made an appearance on the palm of your right hand, indicating that you're overdue for some exercise. You go to the gym, and by the time your workout is over, the star has faded away. Later, if you skip a couple of workouts, the star comes back. If the star comes back and you don't do anything about it, more stars begin to appear. The next time you go in for a checkup, and your doctor sees that your palm looks like the Andromeda galaxy, you can expect to get a talking-to.
The program I've outlined here is not yet available, and to be honest I foresee some barriers to its implementation. The technical difficulties wouldn't be the biggest barrier, either: expecting a medical office to communicate with its customers as willingly as a Honda dealership does is probably expecting far too much. But, in principle, it would be useful to have something installed in us which monitors our health, or at least reminds us of the things we need to do to maintain our health.
For now, though, we just have to do it manually. (Or else blog about our health, so that everything is tracked in an embarrassingly public way -- maybe that's the solution!)
Thursday, May 13, 2010
Fasting Glucose: 89.
Blood pressure, resting pulse: 108/66, 53.
Exercise: 4.1-mile run.
For a long time it was believed that King Henry VIII died of syphilis, but lately medical scholars have been drawn to another theory: that his peculiar health problems (debilitating joint pain, leg ulcers, a collapsed nose, severe headaches, and extreme emotional instability in later years) might be explained equally well, if not better, by malnutrition.
At first glance it seems absurd to think that a king, and a fat king at that, could die of malnutrition. But in Henry's day, it was quite possible, simply because it was assumed then that the only dish fit for a king was meat. Vegetables were for the common folk. As a result, Henry ate a diet which, although high in calories, was deficient in certain vitamins, particularly vitamin C. By eating a diet free of "produce", Henry made himself as vulnerable to scurvy as a sailor voyaging to the new world. Eating something green once in a while might have helped him greatly, but it would have been beneath him -- plant foods were for peasants. (Having six wives might not have been so good for him either, but his diet was probably the worst lifestyle choice he made.)
Whether you want to go as far as becoming a vegetarian or not, it seems clear that eating a variety of plant foods is indispensable to a good diet. Nature does its best to lure us into sampling many vitamin-rich foods, by giving them striking colors. Maybe that's why a collage of vegetables looks like the very emblem of health, and a collage of meats looks like horror-porn.
In fact, one reasonably good strategy for achieving a healthy balance in your diet is to eat meals that feature a lot of color contrast. If everything on your plate is white or brown, something's missing.
Wednesday, May 12, 2010
Fasting Glucose: 90.
Blood pressure, resting pulse: 110/73, 58.
Exercise: 7.3-mile run.
I usually do a long trail-run at least once a week, and it dawned on me today that I hadn't done a single one in the last 18 days. So, instead of running at lunchtime, I headed over to the state park in the evening. I managed to finish my 7.3-mile route well before sunset. Much as I dislike the general concept of Daylight Saving Time, I am quite willing to take advantage of the one thing that's good about it.
The park was beautiful, particularly the meadows full of grass and wildflowers. Normally the grass would be drying out and turning beige by now, but the late rains have kept it bright green for a little while longer. It was a bit of Ireland, transported to California.
The trails were nearly deserted this evening. And yet, in one of the more remote corners of the park, I heard someone call my name, and realized I had crossed paths with the wife of one of my running buddies at work. It's one of the things I like about trail-running: you're mostly alone, but you do run into people, and sometimes they're people you know.
I'm now in that peculiar trough that follows a big, challenging event. The concert series that we concluded on May 2nd, and which was an intense focus of my life for a couple of months, is history now, and I'm feeling slightly adrift.
I do tend to commit myself to challenges that command my full attention for a time, and leave me feeling aimless and confused when they're over. Marathons are another example. It's good to have that kind of intense focus on a project, and it's also good to have the relief of being done with it -- but it's hard not to feel that these things have left a void behind them when they've come to a conclusion.
Oh well -- find some other challenge!
I haven't done any organized athletic events in a while (the half-marathon on Halloween was the last one), so I guess that something like that should be my next project. I'm looking at a few possibilities.
I'm signed up to do the Bay To Breakers run in San Francisco on Sunday, but that's not exactly a serious athletic event, except for a few elite runners from Kenya who are placed in front of the crowd. The rest of us have to hang back, with tens of thousands of people in our way, and for the first few minutes after the starting gun you can't even walk, much less run. Because the event cannot be a serious race under the circumstances, people make it into a kind of outdoor frat party instead.
Of course, you do have to get from one side of the San Francisco peninsula to the other, and the distance is 7.5 miles, with a substantial hill in the middle of it, so it has to count as a workout even if you are just walking the whole thing (and thousands of participants do just that). It's certainly not the sort of event where you're trying to beat your pace from last year. Your pace is determined largely by how many goofy people are in your way, and there can be an awful lot of them.
Running in costume is a popular thing in this race, but every time I think that maybe I ought to run in costume this time, I ask myself what kind of costume could be so comfortable that I would want to run in it for 7.5 miles -- and then I drop the idea at once. I mean, the people dressed as cafe tables last year were fun to look at, but can you imagine running a long race that way?
Some people run the race without a costume -- and without clothes in general. I don't know who started this nude-runner tradition, or when, but it is so well-established now that no one takes seriously the ritual announcement by the police department that this time they're cracking down on it. (Yeah, right. You said that last year, too.) If you run in Bay To Breakers, you take it for granted that you're going to see a fair number of naked runners -- many of whom should not even be allowed to take their clothes off in their own homes, much less on Hayes Street. But, as the saying goes, the people you get to see naked are seldom the people you want to see naked. Which is why I won't show you a great photo I found of a San Francisco cop looking firmly the other way while a bunch of unattractive nudists ran past him. You don't want to see that one, trust me. I looked at it so you don't have to.
Well, I'll do the race, and not worry too much about how fast I can do it. It's really just a party, and I'll participate in it on that basis.
Tuesday, May 11, 2010
Fasting Glucose: 82.
Blood pressure, resting pulse: 117/81, 42.
Exercise: 5.5 mile run.
Gorgeous weather for a run today. Sunny, clear, low 60's, no wind. Yesterday's rain seemingly cleared all the pollen out of the air, so I was able to do a long run at lunchtime without fear of having red swollen eyes all afternoon. I went up on the ridge road to take in the view and make the work world go away for a while.
Among the things at work I was getting away from: I spent the morning trying (and ultimately failing) to convince our software team that, if you are inventing a programming command which controls the "Analyzer" part of the instrument, it's really not a good idea to give this command the name "ANAL". They said the formal conventions of the SCPI programming language made it necessary to abbreviate the name in just that way. So now it's my job to explain to our customers how to conrol the analyzer, without making it sound as if the command they need to use for this purpose was my idea.
It didn't do me any good when I pointed out that they had, in the past, made at least one exception to formal conventions, back when we hired a new engineer from Japan. They used to assign everyone a Unix login names that consisted of their first name plus the initial of their last name (David Porter would be "davidp", I was "tomr", and so on). But, as I say, they agreed to abandon this convention in one instance, when they hired Takashi Tsuboi, who for some reason objected to logging in as "takashit".
But that was different, apparently. My anecdote amused, but did not persuade. Our Analyzer command is "ANAL", and "ANAL" it will remain.
They must be reading my mind (or anyway my blog) over at dLife. Last night I wrote at length on the subject of "eating too much"; this morning they sent me an e-mail with the subject line "Do You Eat Too Much?", and referring me to an article they published today on portion sizes.
Surprise: portions are actually supposed to be a lot smaller than most of us think! Here are some example portions, compared to objects of the same volume:
|Serving Size||Comparable Object|
|Cold cereal: 1 cup||Tennis ball|
|Hot ceral, pasta, rice, mashed potatoes: 1/2 cup||1/2 a tennis ball|
|Meat, beans, eggs, nuts: 3 ounces||Deck of cards|
|Peanut butter, almond butter: 2 tablespoons||Ping pong ball|
|Cooked or raw vegetables (leafy greens excepted): 1/2 cup||1/2 a tennis ball|
|Leafy greens: 1 cup||Tennis ball|
|Cheese: 1.5 ounces||4 dice|
|Ice cream: 1/2 cup||1/2 a tennis ball|
|Fruit: 1/2 cup||1/2 a tennis ball|
Now, these serving sizes are the USDA's definitions of servings -- as in "you should have 2 to 4 servings of fruit a day". But keep in mind that, based on these sizes, the typical apple counts as two servings rather than one.
I don't think there can be many people out there who would regard a mound of mashed potatoes or ice cream that's only half the size of a tennis ball to be a full serving, but that's the way these things are defined.
It's worth keeping in mind, anyway.
I continue to be amazed by the passion with which many Type 2 patients object to (1) any suggestion that the disease is connected to lifestyle, and (2) any suggestion that people with Type 2 can do something about it.
Some people insist that Type 2 is purely genetic (lifestyle has nothing to do with it!), and also that it's an uncontrollable downhill slide which cannot be remedied. And they stand ready to launch a protest if a journalist or broadcaster says anything which seems to contradict these views.
I doubt that they are thinking this through as carefully as they ought to.
Of course your genes can increase your risk of becoming diabetic. That's not even controversial. Quite a few specific gene mutations have been implicated in Type 2 diabetes.
One of the better-understood examples is the TRP64ARG mutation of the Beta3-Andrenergic Receptor gene. The frequency of this mutation varies between ethnic populations, and tracks very well with the rates of obesity and diabetes in those populations. The gene makes a protein in fat cells which controls how fast the body burns fat. The mutation of that gene causes it to make an ineffective version of the protein, so that you don't burn fat as efficiently, and this makes it easier for you to gain weight. The name of the mutation, "TRP64ARG" is a tangled reference to the amino acids Tryptophan (TRP) and Arginine (ARG), and to the 64th position in the protein strand. That 64th amino acid on that strand should be Arginine, but if you have this mutation it's Tryptophan instead -- which screws up your fat-burning protein, so that your odds of becoming obese and diabetic are increased.
This mutation is four times as frequent among the Pima Indians (famous for their high susceptibility to diabetes) as it is among Caucasians. This is seen as a smoking gun.
But hold on a minute! Does having the TRP64ARG mutation of the Beta3-Andrenergic Receptor gene mean that you're sure to get diabetes, and nothing can be done about it? Actually, no. Not everyone with this mutation becomes diabetic; they're just more likely to. And it matters how they live. The Pima Indians straddle the US/Mexico border, and although their mutation rate is the same on either side of the border, their lifestyle on the Mexican side of that border tends to involve less eating and more physical work -- and the diabetes rate there is lower; surprise, surprise!
There are other known or suspected diabetes-related genetic mutations out there. In fact, there are at least 16 of them (it's hard to keep track -- 13 of those were discovered since 2007). But these genetic mutations don't give you a certainty of becoming diabetic, only an increased risk of it. And the increase in risk is not necessarily large: often less than 40%. (And that doesn't mean a 40% risk of developoing diabetes, only a 40% increase in the normal risk of developing diabetes, which is not very high).
Because these mutations only increase your odds of becoming diabetic, they have to be interacting with non-genetic factors which might be present and might not, depending on how you live your life. So, lifestyle makes a difference, regardless of which genetic mutations you are carrying.
A few people must be carrying several of these diabetes-related mutations at once, which I guess is why we sometimes hear about thin, active people who nevertheless develop Type 2. Maybe, when the genetic deck is stacked heavily enough against you, no lifestyle you can adopt will prevent diabetes, or even ameliorate it very much.
However, I would hate to see people leaping to the conclusion that they were damned in the womb with a certainty of developing uncontrollable diabetes, and they shouldn't be asked to try to do anything about it.
It would be silly to claim that Type 2 has nothing to do with genes. It would be every bit as silly to claim that Type 2 has nothing to do with lifestyle. But, if you are going to ignore one of those two issues, which one should it be? I'd vote for ignoring the issue that you can't do anything about anyway (genes) and concentrating on the one that you can do something about (lifestyle). The advantage of this approach is that it gives you your best shot at staying healthy.
Some people with Type 2 prefer to ignore the issue that they can do something about, and concentrate instead on the issue that they can't do anything about. The advantage of this approach is... well, I guess it's whatever emotional satisfaction people get out of dwelling on their victimhood.
Seems like a really lousy trade to me!
Monday, May 10, 2010
Fasting Glucose: 88.
Blood pressure, resting pulse: 119/82, 53.
Exercise: 5.3 mile run.
Up two pounds! It sure doesn't take long for that to happen. I had a restaurant meal on Saturday, and a winery picnic on Sunday (with an extended afternoon of munching down cheese and olives and other calorie-dense treats). My weekend of indulgent eating had an impact, clearly.
My fasting test of 88 this morning wasn't bad considering; my hard run yesterday helped me with that (so I did exactly the same run today, seizing a sunny opportunity in an otherwise rainy day), but running is never enough to prevent weight gain when you're eating too much.
I'm perfectly willing to accept that, if my weight is going up, it means I'm eating too much. Some people don't accept this, and they have a lot of ingenious rationalizations at the ready to justify their point of view. They may be gaining weight, but it certainly isn't because they are eating too much! There are other reasons. Their metabolism is different. Their body absorbs calories more efficiently than other people's bodies do. Their body doesn't burn calories as readily as other people's bodies do. Anyway, they aren't eating too much!
Here's the problem I have with that point of view: unless you're thinner than you ought to be, gaining weight is simply the definition of "eating too much". How else could "eating too much" be defined? If nobody ever gained weight, we wouldn't have any objective way to determine how much food was too much. But people do gain weight. Therefore, if you want to know if you're eating too much, the answer is "yes" if you're gaining weight and "no" if you're not.
Certainly, people differ in their physiological traits. Some people do burn more calories per hour (even at rest) than others do, either because of their size, their metabolic rate, or even how restless and fidgety they are. Some people do seem to be able to extract more energy from the same food than others do (one study claims to show that this is largely owing to different species of intestinal bacteria in different individuals). But whatever factors might contribute to these individual variations, the bottom line is that the variations exist -- and therefore it is impossible to design a diet and a set of portion sizes, and say: "this amount of food is just enough, and eating any more than this is too much". It might be too much for one person, and not enough for another. There is no daily calorie count that is going to turn out to be the right amount for everone. Fortunately, there is a simple and objective test that we can apply: if you're gaining weight, you're eating too much. Whatever amount of food makes you gain weight is, for you, too much.
Of course, another factor affecting weight is appetite, and in some people (particularly people with Type 2) the appetite-control mechanism is not working very well. I can see how this would lead to a person eating too much, but some people seem to think it invalidates the claim that they are eating too much -- and I don't see how it does. The fact that you can't help eating too much can scarcely serve as proof that you're not eating too much.
Maybe what these people are getting at is that it's not fair to say they're eating too much, if they know someone who eats just as much and is thin. That's like saying it's not fair that they're allergic to Acacia pollen and some people aren't. What of it? The fact that the amount of food that counts as too much for you wouldn't count as too much for someone else is irrelevant. If it's too much for you, it's too much for you. And if you're gaining weight, that means it's too much for you.
I'm not saying it's easy to avoid gaining weight. Understanding the problem is one thing, and solving it is another. Obviously, I find it hard to avoid gaining weight. But the reason I find it hard is that the amount of food I want to eat (and which doesn't seem like too much to me), is in fact too much -- if we judge it by the only criterion that really counts.
All these studies of individual variations in physiology seem to me to prove nothing more than that it's harder for some people than others to avoid eating too much. They certainly don't prove that eating too much is not the issue here.
Sunday, May 9, 2010
Fasting Glucose: 80.
Blood pressure, resting pulse: 126/73, 58.
Exercise: 5.3 mile run.
I wen't running first thing in the morning today -- something which I seldom do, but I had plans for the day and I wanted to get my workout out of the way early. I have mixed feelings about running in the morning, and today's run didn't change that.
On the plus side, running early in the morning feels better than running later in the day, although it's hard to say way. There's something different about the air. There's a special mood. Particularly on a Sunday, when the world is not in a hurry to wake up. I was feeling good, even on the steep climbs (and there are some very steep ones on the route I was following).
On the other hand, there's the empty-stomach issue. My fasting result was pretty low this morning (80), and I worried that if I ran without having breakfast, I might run out of gas half-way through the run. I didn't actually think I would get a serious enough case of hypoglycemia to put me in any danger. For me, hypoglycemia isn't a safety issue, just a misery issue. But the misery could have been substantial, if I found that I had to stop running, and then realized that my home was 2 miles away and 500 feet uphill.
Yet, if I had tried to solve the empty-stomach issue by having breakfast first, I would then be dealing with the full-stomach issue. Running after eating usually makes me feel awful, and it's worse in the morning. If I ate first, I would have to delay the run for at least an hour while I digested breakfast, and I wanted to get a move on.
Well, I took the chance, and it all worked out. It was a good run. When I finished it, I thought "I should do this more often". And then I thought "There are perfectly good reasons why I don't do this more often." Mixed feelings to the end.
Volatile weather today. It was sunny when I started my run, but thick clouds started rolling in before I was done with it.
There ended up being a little light rain, and one brief but heavy downpour. But lots of sunny episodes, too. Had a nice picnic at the Michel-Schlumberger winery. There has to be some reward for being a good boy and getting your miles in.
Friday, May 7, 2010
Fasting Glucose: 84.
Blood pressure, resting pulse: 117/79, 54.
Exercise: 4.6 mile run.
Earlier this year, the American Diabetes Association finally recommended use of the Hemoglobin A1c test as a diagnostic indicator for diabetes. (Their next breakthrough, I imagine, will be to accept breathing as a valid iindicator of whether or not someone is alive.)
Anyway, now that the ADA has finally decided that reality is a valid ingredient of policy, we must assume that the A1c test will now be given a lot more often -- not just to people who are already known to have diabetes, but also to people who are merelyt at risk for it.
Until now, the A1c test has only been used to as a kind of progress report on how well a diabetes patient is controlling his or her blood sugar. If the test is now going to be given to a bunch of people who don't even know that they have diabetes, it could be that the test will have more to tell us than it has been telling us so far.
A recent Medscape article discusses the relationship between Hemoglobin A1c test results and the risk of CVD (cardiovascular disease, to you and me). And the relationship is more dramatic than you would expect:
|A1c result||Risk Factor|
|5% to 5.5%||1.00 (reference)|
|5.5% to 6%||1.86|
|6% to 6.5%||4.48|
The risk of CVD, as related to the A1c test, is said to exhibit a "J-shaped curve". That is, the risk starts out low, and soon starts to rise very, very steeply as the A1c result climbs. Notice the dizzying increasse in the risk factor as the A1c result goes from below 6.5% to above 6.5%. Would you have expected that the risk could more or less quadruple as a result of crossing this frontier? I would not have, but that seems to be the reality.
Pulblicizing this kind of risk analysis is likely to upset people, but maybe that's all the more reason to make it more widely known. We might as well know what we're dealing with here.
The risk of cardiovascular disease is elevated in people with diabetes, and the risk rises sharply as the A1c result goes up. It's for this reason that I believe medication and dietary adjustments can never be an adequate solution to the diabetes problem, if you don't add exercise to the mix. You have to do something about the elevated CVD risk that comes with diabetes -- and exercise is the only thing I know of that makes a big difference.
Thursday, May 6, 2010
Fasting Glucose: 81.
Blood pressure, resting pulse: 117/72, 54.
Exercise: 4.1 mile run.
Ah, 81 -- that's more like it. At least, so far as I know, it is. Given the vagaries of glucose meters, my result of 81 this morning could have been lower than the actual value. My reading of 96 yesterday could also have been higher than the actual value. In theory, we should simply ignore these day-to-day fluctuations (which may be nothing more than artifacts of a somewhat rickety measurement process), and only pay attention to averages. In theory, as I say.
But life happens on a daily basis, not on an average basis. Waiting for a few weeks to build up solid statistical confirmation that, indeed, you've been taking in too much carbohydrate lately doesn't sound like an entirely realistic plan.
Maybe the only practical thing to do is to pay very serious attention to day-to-day fluctuations, and take corrective action whenever there is an uptick. Sometimes you'll be over-reacting to an overstated reading (and sometimes you'll be under-reacting to an understated reading, too), but if you keep on taking the numbers seriously, on average you'll be right. Which, I guess, is effectively the same thing as paying attention only to the averages -- except that it's humanly possible.
I haven't a clue what my fasting result will be tomorrow morning (probably not as low as 81, hopefully not as high as 96), but whatever it is, I'll assume that it means something, and respond accordingly. What else can I do?
Only a short time ago (see my April 26 blog post) I was commenting on how conspicuously fit are the people who live in San Francisco, in comparison with the tourists who waddle amongst them. Apparently I'm not the only one who has picked up that impression. Men's Health recently ranked cities in the United States from fattest to leanest, and San Francisco ranked as the leanest. Here are some San Franciscans, hanging around being lean:
The fattest city in the nation turns out to be Corpus Christi, Texas. Remarkably, of the 10 fattest cities, half are in Texas (the others are El Paso, Dallas, San Antonio, and Houston). No other state has even 2 cities in the top 10. Texas has 5.
And yet, oddly enough, Texas also managed to get one of its cities among the 5 leanest: Austin. But, since Austin seems to be regarded within Texas as the least Texas-like of its communities, maybe it makes sense in some way that, if Texas had a lean city, Austin would have to be it.
You might ask how Men's Health arrived at its rankings. Did they just wander around from town to town, taking pictures of people in the shopping malls? Well, you could choose worse methods, but the people at Men's Health say it was all far more scientific than that. The relied on published statistics regarding public health in the various cities (obesity rates, diabetes rates, fitness levels) and also commercial statistics (junk food sales, for example). I'm sure that this approach could be challenged on all sorts of methodological grounds (how do we know that public health statistics aren't gathered and evaluated differently in different locales, thus distorting the rankings?). So maybe the report has got it all wrong, and it's the Texans who are thin, not the San Franciscans. Maybe the Texan on this airplane is not the one you think!
I'm skeptical of that, though. I've seen San Franciscans, and I've seen Texans, and I know which of them looked bigger to me. Could be a sampling error, though: I haven't seen all San Franciscans, or all Texans. Houston could be full of skinny people who never go out, for all I know.
Assuming that the rankings reported by Men's Health are at least roughly accurate, there could be a hundred different reasons why people are fatter in one city than in another. But I think one important factor would have to be social pressure. My guess is that people in San Francisco are simply expected by their peers to stay in shape. It's an outdoorsy kind of city, and when you're making an appearance along the waterfront you're supposed to look good enough in your exercise clothes to differentiate yourself sharply from the tourists. Maybe people who live in Corpus Christi just aren't under that kind of pressure.
Probably attitudes toward food differ a lot from place to place, also. In San Francisco, there is more of an attitude of connoisseurship about food. Getting a recipe just right is a higher goal than serving a huge platter of it. Perhaps, in Corpus Christi, it's all about generous portions.
But whatever the reason is (or the 25 reasons are) for the comparative leanness of San Francisco, it's got to relate to the way people are living there, not the way people's genes are there. Local populations can differ genetically, if they're isolated enough, but to the extent that there is a San Francisco gene pool, it's all imported. Hardly anyone in San Francisco is from there. Being San Franciscan is something that people decide to do. Or, to be more blunt, being San Franciscan is something that people decide they can now afford to do. The old San Franciscans got priced out of the place years ago. So everybody's from someplace else, and if they have anything in common, it's the set of things they decided to become once they got there. Adopting a fake (and highly weird) California accent is part of the picture. Getting in shape is, apparently, part of the picture too.
Wednesday, May 5, 2010
Fasting Glucose: 96.
Blood pressure, resting pulse: 110/72, 54.
Exercise: 5.3 mile run.
I was hoping to improve my fasting test by a little more than one point today, but I think I put myself in the hole with all that eating and non-sleeping over the long concert weekend (followed up by a party on Monday evening), and I'm still crawling out of it. I guess it will take me a while to work myself back down to where I belong. Where I belong, or so I believe, is the 80s, and preferably the low 80s. I've achieved it before, and I'm sure I can achieve it again. But today's Cinco de Mayo celebration at work didn't help me any!
96 is still officially "normal" for a fasting test, (my doctor only asked me to keep it under 110), but I ought to be doing better than that, and I'm embarassed to have to report that I'm not, after bragging about doing a lot better a few months ago.
But I guess that's one of the reasons I started this blog -- to embarass myself when I'm drifting off course, and put more pressure on myself to do better.
Cinco de Mayo (the 5th of May) is one of those peculiar ethnic holidays which, like St. Patrick's Day, is celebrated more in the United States than it is in the nation it comes from. A lot of Americans imagine that Cinco de Mayo is Mexican Independence Day (no, that's September 16th -- a far more important holiday in Mexico than May 5th is).
Cinco de Mayo actually commemorates the Mexican army's against-the-odds victory over the French army at Puebla, in 1862. And what were the French doing in Mexico in 1862? Initially, trying to force Mexico to pay interest on money it owed to France, but after a while the French thought that, as long as they were already in Mexico anyway, they might as well try to take over the country. It didn't work out.
In Puebla itself, Cinco de Mayo is celebrated, but the rest of Mexico pays little heed to it. It's a bigger deal in the US, where it is seen as a kind of ethnic-pride festival for Mexican-Americans, in the same league with St. Patrick's Day, Oktoberfest, and Chinese New Year. Perhaps all this sounds odd and unfamiliar, if you live in the part of the US where there isn't a large Mexican-American population. That's certainly not the case where I live. I think there's about as much Spanish as English spoken in Sonoma County.
Anyway, nothing says "ethnic pride" like eating and drinking, let's face it. We had a big Mexican pot-luck luncheon at work, I guess mainly because we hadn't had any kind of celebration in a while and we were looking for an excuse.
I didn't have any of the Corona beer that was available, and I skipped the rice and taco chips. But I did fill my plate, and unfill it at a remarkable pace. I think tomorrow would be a good day for much more modest eating.
Later in the afternoon: dramatic announcements at work. I'm not at liberty to discuss what's up (even though I haven't been telling you where I work), but I can at least say that I'm not losing my job as a result of it. Still: drama.
I don't like drama, I've decided. It's okay on stage. At the office, no thank you. I would like events to evolve very gently and gradually at work. Unfortunately, that's not how it works.
Because my lunchtime was taken up with the luncheon at work, I had to put off exercise until the evening -- a very hilly run. Actually, that's a very appealing time of day for a run, if you ask me. I finished just after sunset, getting back home in the fading light. I don't know exactly what it is that makes me enjoy exercising at that time of day, but I do enjoy it. The main reason that I usually work out at lunchtime is that I have running buddies to accompany me then, and in the evening I'm usually alone. Well, the advantage (and also the disadvantage) of exercising alone is that you get to set your own pace, so the run was easier for me than it would have been if I were trying to keep up with someone else.
And the evening light is beautiful here. Maybe that's all there is to my preference for running at sunset.
I got a little more sleep last night than I have in a while, but I need to do better tonight. I was still sleepy in the afternoon at work. I could claim that this was because the Mexican lunch was making me crave a siesta, but I was sleepy at the same time yesterday, too. Maybe I just need to drink less coffee in the daytime.
Tuesday, May 4, 2010
Fasting Glucose: 97.
Blood pressure, resting pulse: 126/76, 57.
Exercise: 5.2 mile run.
Hmmm, 97. Not my idea of an acceptable fasting test result, but not too surprising either. Yesterday, when I should have been subsisting on lettuce and water (to make up for the 72-hour buffet that was our long concert weekend) I attended a dinner party instead. And the dinner was Chinese -- by which I mean an actual Chinese at-home dinner, which is not the same kind of thing as a Chinese restaurant dinner. Many courses, and many food items which were extremely unfamiliar to me, so that I had almost no idea what sort of things I was eating. Why is this bean dish so sweet? (Because it's a dessert, actually.) Why is this olive so leathery? (Because it's a quail egg that's been given a lot of treatment.)
Yesterday wasn't really the right time for me to go to dinner party, but I didn't feel I could miss it. It was my chance to see an old friend who lives in Japan now, and was here on a short visit. I hadn't been able to see him on the weekend because I was completely tied up with the concerts. If I skipped the dinner, I wouldn't see him at all. So, I went.
And now I'm looking at the prospect of a big Mexican meal at work tomorrow -- a pot-luck luncheon for Cinco de Mayo. I had agreed to participate in it some time back, and tonight I'm making salsa to bring with me to the office tomorrow. My salsa is pretty good, but unfortunately you have to put it on something, and the usual thing to put it on (taco chips) is not an especially diabetes-friendly food.
It's just the luck of the draw, but sometimes I find myself more or less trapped and surrounded by overabundant food, for several days in a row. It isn't just Christmas that does this to us; social activity of any kind always seems to be organized around overeating. What's the remedy, though? Being unsociable? That harms you in other ways. Persuading society to redefine social life so that feasting isn't an important part of it? Not likely to happen. Attending the event and just staring at the food without eating it? I haven't learned how to accomplish that one. I don't know what the solution is, but I'm terribly afraid it might have to involve moderation on my part.
I have a very American reaction to the word "moderation": it makes me wince. I may not be a typical American in most ways, but I haven't neglected that part of my heritage.
Another problem, of course, is that I lost a lot of sleep during the concert weekend and haven't made up for it yet. Losing sleep certainly doesn't help my blood sugar control. I'll try to get to sleep earlier tonight.
I am writing to you from Sonoma County, California -- the pollen capital of the United States (or so they tell me).
If you're allergic to grasses (and I am), May is mighty tough time to be going outside in these parts. Which means that it's a tough time to exercise, if you greatly prefer outdoor exercise to the gym (and I do).
Today wasn't bad, actually. Sunday was a nightmare. I went running in the morning before the Sunday concert, and my eyes got so irritated that I was practically blind by the time I staggered home. I had to take out my contact lenses, and didn't dare put them back in all day (if your eyes are irritated by pollen, contacts make the problem a lot worse). That's why I'm wearing glasses in that picture of the concert from yesterday.
But it was cooler and less windy today, so the pollen wasn't too bad. May that trend continue!
Monday, May 3, 2010
Fasting Glucose: 93.
Blood pressure, resting pulse: 121/77, 52.
Exercise: 4.1 mile run.
The concerts (that is, the spring concerts of the San Francisco Scottish Fiddlers) concluded yesterday with a performance in Santa Rosa, California, and I have to admit that I'm a little tired. The concerts went splendidly -- better than I would have imagined as the best-case scenario, considering how thoroughly the concerts had to be re-conceived in a few days, when our director/soloist had to drop out due to the death of his father (who was himself a highly popular member of the group). The emotional strain of "going on with the show" in the midst of grief seemed to exhaust people more than the physical strain, the lack of sleep, and the nervous tension that always comes with being on stage.
On the other hand, the extraordinary challenge we were taking on seemed to inspire everyone to give a hundred percent. I think I've already said that we were putting a very large ensemble on stage. To appreciate just how large, you have to check out this photo of our performance yesterday. Not the easiest thing in the world to get a band that size playing together well. Or even to get them fed.
We certainly had the "getting fed" part of the equation covered. If an army travels on its stomach, so does an orchestra. I'm glad my numbers this morning weren't worse. At least I did manage (against all odds) to get my exercise in during the weekend. But I didn't get my sleep in, so I'd better go to bed now and get caught up on that.
If you didn't spot me in the other photo, I'm a little easier to find in this one -- they guy in the red vest on the left, who shouldn't have held his head at that revealing angle while the photographer was there.
"NOT MEDICATED YET"
Reading the Stats
What this is about
I am going to use this space to report on my daily process of staying healthy -- what I'm doing, and what results I'm getting, and how I interpret the connection between the two.
I am not trying to taunt anybody, by reporting better results than they are getting themselves. I'm doing this to provide encouragement, not irritation.
Regardless of what your own health situation is now, you can probably pick up some useful ideas by tracking what I'm doing, and seeing what the results are. I don't mean that you should do whatever I do, or that imitating my behavior will get you the same results I get. We all have to figure out what works for us. Let's just say that I'm giving you an example of some things to try, and they might help. If they don't, try something else!
One word of warning: I sometimes participate in endurance sporting events (including "century" bike rides and the occasional marathon), but please don't assume that you would have to participate in extreme sports to get the kind of results I'm getting. Most of the year I'm not working out nearly that hard, and I still get very good results. For some people, vigorous walking may be enough. (But if it isn't in your case, don't cling to the idea that it ought to be enough -- do whatever it takes to get good results!)